Self-Study Modules on Tuberculosis

Epidemiology of Tuberculosis

1

Introduce Module 2

Ask participants if they know what epidemiology is

Module 2: Objectives

     At completion of this module, learners will be able to:

Describe how the number of TB cases reported in the U.S has changed over the last 60 years

List 5 factors that contributed to the increase of TB cases between 1985 and 1992

List 3 improvements TB programs made with increased funds that have contributed to a decrease in TB cases since 1993

List groups of people who are more likely to be exposed to or infected with M. tuberculosis

List groups of people who are more likely to develop TB disease once infected with M. tuberculosis

Module 2 – Epidemiology of Tuberculosis

2

State objectives of presentation 

Background and Objectives - Module 2, p. 1

2

Module 2: Overview

Introduction to TB Epidemiology

People at High Risk for TB Infection and TB Disease

Case Studies 

Module 2 – Epidemiology of Tuberculosis

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Review slide content 

3

Introduction to TB Epidemiology

4

Introduce section

Epidemiology of TB - Module 2, pp. 3-5

4

Epidemiology (1)

Epidemiology is the study of the distribution and causes of disease and other health problems in groups of people.

Module 2 – Epidemiology of Tuberculosis

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Ask for a volunteer to read the definition of epidemiology 

Epidemiology definition - Module 2, p. 1

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Epidemiology (2)

Epidemiologists:

Determine frequency and pattern of health problems in communities

Try to figure out why health problems are occurring

Module 2 – Epidemiology of Tuberculosis

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Review slide content 

Epidemiology - Module 2, p. 1

6

Global Epidemiology of TB

TB is one of the leading causes of death due to infectious disease in the world

Almost 2 billion people are infected with M. tuberculosis

Each year about:

9 million people develop TB disease

1.5 million people die of TB

Module 2 – Epidemiology of Tuberculosis

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Before showing slide, ask how many people in the world are infected with TB  

State that 1/3 of the world’s population is infected with TB

Review slide content

Global Epidemiology of TB - Module 2, p. 3

7

TB Reporting in U.S.

The Report of Verified Case of Tuberculosis (RVCT) is the national TB surveillance data collection form and is used for reporting all  verified TB cases to CDC

The 50 states, District of Columbia, New York City, Puerto Rico, and 7 other jurisdictions in the Pacific and Caribbean report TB cases to CDC

Health care providers are required by law to report TB cases to state or local health departments

Module 2 – Epidemiology of Tuberculosis

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Review slide content

TB Reporting in the U.S. - Module 2, p. 3 

8

U.S. Epidemiology of TB1953 - 1986

1953:  

More than 84,000 cases of TB

1953-1984:  

TB cases declined about 6% each year

1985:  

TB cases reached a low of 22,201

1986:  

Significant increase in TB cases began

Module 2 – Epidemiology of Tuberculosis

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9

Review slide content

Emphasize that from 1953-1984 TB cases were declining

Explain that one of the main reasons for this decline was that TB treatment drugs were discovered in the 1940s and 1950s

U.S. Epidemiology of TB - Module 2, p. 4

U.S. TB Resurgence (1)1986 - 1992

Module 2 – Epidemiology of Tuberculosis

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Reported TB Cases, U.S., 1982-2014

No. of Cases

10

Review slide content

Call attention to the increase in TB cases on the graph (1980s)

Ask participants why they think there was 20% increase in TB cases in the 1980s

U.S. TB Resurgence - Module 2, p. 4

U.S. TB Resurgence (2)1986 - 1992

Contributing factors:

Inadequate funding for TB control and other public health efforts

HIV epidemic

Increased immigration from countries where TB is common

Spread of TB in certain settings (e.g., homeless shelters and correctional facilities)

Spread of multidrug-resistant TB (MDR TB)

Module 2 – Epidemiology of Tuberculosis

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Explain that there were several contributing factors to the TB resurgence in the U.S. 

Review slide content

 U.S. TB Resurgence - Module 2, p. 4

11

U.S. TB Control and Prevention (1) 1993 - 2014

1993-2014:

Number of TB cases reported annually in U.S. steadily declined 

Increased federal funds and other resources allowed TB programs to improve control efforts to:

Promptly identify persons with TB

Start appropriate initial treatment for TB cases

Ensure patients complete treatment

Conduct contact investigations

Module 2 – Epidemiology of Tuberculosis

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Review slide content

Stress that prevention and control efforts must be maintained in order to prevent another resurgence

U.S. TB Control and Prevention - Module 2, p. 5

12

U.S. TB Control and Prevention (2)1993 - 2014

Module 2 – Epidemiology of Tuberculosis

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Reported TB Cases, U.S., 1982-2014

No. of Cases

13

Call attention to the decrease in TB cases on the graph (after 1993)

State that there were 9,421 TB cases in the U.S. in 2014

U.S. TB Control and Prevention - Module 2, p. 5

Continuing Challenges in TB Control 

TB is reported in almost every state and is increasing in some areas

More than half of all TB cases in the U.S. are among foreign-born persons

TB affects racial/ethnic minorities disproportionately

MDR TB and extensively drug-resistant TB (XDR TB) remain serious public health concerns

Module 2 – Epidemiology of Tuberculosis

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Explain that there remain several areas of ongoing challenges in TB control 

Review slide content

Continuing Challenges in TB Control - Module 2, p. 5

14

TB Case Rates (1)

A case rate is the number of TB cases that occur during a certain time period, divided by size of the population at that time

Often expressed in terms of a population size of 100,000 persons

Module 2 – Epidemiology of Tuberculosis

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15

Review slide content

TB Case Rate - Module 2, p. 5

TB Case Rates (2)

Example:

In the U.S. in 2014, there were 9,421 new TB cases in a population size of 318,857,056

                          9,421       x  100,000 =  2.96

                      318,857,056

In 2014, the U.S. TB case rate was 2.96 TB cases per 100,000 persons (rounded to 3.0)

Module 2 – Epidemiology of Tuberculosis

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Use the example on slide to demonstrate how to calculate a case rate

TB Case Rate - Module 2, p. 5

16

TB Case Rates by State, 2014

Module 2 – Epidemiology of Tuberculosis

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*Cases per 100,000

< 3.0* (2014 national average)

D.C.

Explain that this map shows TB case rates by state 

Ask which states had higher rates and which had lower rates 

Point out the case rates for your area 

Note: Slide reflects 2014 surveillance data

TB Case Rates by State – Module 2, p. 6

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TB Case Rates (3)

Health departments, CDC, and others can compare the occurrence of TB in different places, time periods, and groups of people using case rates

Comparisons have shown that rates of TB are higher in certain groups than in others

Module 2 – Epidemiology of Tuberculosis

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Review slide content

Ask which groups have higher TB case rates

TB Case Rate - Module 2, p. 5

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Epidemiology of TBStudy Question 2.1

	What happened to the number of TB cases in the United States between 1953 and 1984? 

		From 1953 - 1984, the number of TB cases 	reported in the U.S. decreased by an 	average of 6% each year.

Module 2 – Epidemiology of Tuberculosis

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19

Introduce study questions 

Ask participants to turn to p. 7 (if participants have print-based modules)

Ask for a volunteer to read question 

Ask participants for answers

Answers - Module 2, p. 22

	What happened to the number of TB cases in the United States between 1985 and 1992? 

		From 1985 - 1992, the number of new TB 	cases increased by 20%.

Module 2 – Epidemiology of Tuberculosis

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Epidemiology of TBStudy Question 2.2

Ask for a volunteer to read question 

Ask participants for answers

Answers - Module 2, p. 22

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	Name 5 factors that may have contributed to the increase in the number of TB cases between 1985 and 1992. 

Inadequate funding for TB control and other public health efforts

HIV epidemic

Increased immigration from countries where TB is common

Spread of TB in certain settings (e.g., correctional facilities and homeless shelters)

Spread of MDR TB

Module 2 – Epidemiology of Tuberculosis

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Epidemiology of TBStudy Question 2.3

Ask for a volunteer to read question 

Ask participants for answers

Answers - Module 2, p. 22

21

Epidemiology of TBStudy Question 2.4

	What happened to the number of TB cases in the United States from 1993 to 2014? 

	From 1993 to 2014, there was a steady decline in the number of TB cases reported annually in the United States.

Module 2 – Epidemiology of Tuberculosis

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22

Ask for a volunteer to read question  

Ask participants for answers

Answers - Module 2, p. 22

Epidemiology of TBStudy Question 2.5

	Name 3 improvements TB programs were able to make with increased federal, state, and other funds that contributed to the decrease in TB cases since 1993. 

Promptly identify persons with TB

Start appropriate initial treatment for TB cases

Ensure patients complete treatment

Conduct contact investigations

Module 2 – Epidemiology of Tuberculosis

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Ask for a volunteer to read question 

Ask participants for answers

Answers - Module 2, p. 22

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Race and Ethnicity (1)

TB affects certain racial and ethnic minorities disproportionately 

In 2014, about 85% of TB cases in the U.S. were among racial and ethnic minorities 

Percentage of TB cases in racial and ethnic minorities is higher than expected based on percentage of these minorities in the U.S. population

Module 2 – Epidemiology of Tuberculosis

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24

Review slide content

Race and Ethnicity – Module 2, p. 8

Module 2 – Epidemiology of Tuberculosis

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Race and Ethnicity (2)

Reported TB cases by race and ethnicity, U.S, 2014*

*All races are non-Hispanic. Multiple Race indicates two or more races reported for a person. Does not include persons of Hispanic or Latino origin.

Explain that this pie chart shows the reported TB cases in the U.S. in 2014 by race and ethnicity 

Ask participants which groups made up the greatest percentage of TB cases, and which groups made up the least 

Reported TB cases by race and ethnicity – Module 2, p. 8

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[CATEGORY NAME]21%[CATEGORY NAME]13%[CATEGORY NAME] [PERCENTAGE]Black or African American	American Indian or Alaska Native	Asian	Hispanic or Latino	Native Hawaiian or Other Pacific Islander	White	Multiple Race	21.335314722428617	1.2525209638042671	31.68453455047235	29.275023882814988	0.97654176838976747	13.257615964334995	2	
Module 2 – Epidemiology of Tuberculosis

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Race and Ethnicity (3)

Racial and ethnic groups by percentage of U.S. population, 2014

Explain that this pie chart shows the U.S. population broken down by race and ethnicity

Ask participants what they notice when comparing this pie chart to the one on the previous slide (e.g., even though non-Hispanic whites make up more than 60% of the U.S. population, they only account for 13% of the TB cases)

Explain that this means that the percentage of TB cases that occur in minorities is higher than expected based on their percentages in the U.S. population

Reported TB Cases by Race and Ethnicity – Module 2, p. 9

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Percent	
White

[VALUE]Hispanic or Latino[VALUE]Black or African American [VALUE]Asian[VALUE]Two or More Races2%American Indian or Alaska Native [VALUE]Native Hawaiian or Other Pacific Islander 0.2%White	Hispanic or Latino	Black or African American	Asian	Two or More Races	American Indian or Alaska Native	Native Hawaiian or Other Pacific Islander	0.628	0.16900000000000001	0.122	4.9000000000000002E-2	2.1000000000000001E-2	7.0000000000000001E-3	2E-3	
Disparities may exist due to racial and ethnic minorities having other risk factors for TB, such as:

Birth in a country where TB is common

HIV infection

Low socioeconomic status

Exposure to TB in high-risk settings

Module 2 – Epidemiology of Tuberculosis

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Race and Ethnicity (4)

Review slide content

Reported TB cases by race and ethnicity – Module 2, p. 9

27

Relative Risk for TB (1)

Relative risk is a comparison of case rates between two groups.

Module 2 – Epidemiology of Tuberculosis

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28

Ask for a volunteer to read the definition of relative risk 

Relative Risk for TB - Module 2, p. 10

Relative Risk for TB (2)

Example:

The case rate for Asians is 17.8 compared to 0.6 for non-Hispanic whites. Therefore, the relative risk for Asians is about 29 times higher than non-Hispanic whites

		17.8 (TB case rate for Asians)           =  29.6

0.6 (TB case rate for non-Hispanic whites)

Module 2 – Epidemiology of Tuberculosis

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Use the example on slide to demonstrate how to calculate relative risk

Note: Slide reflects 2014 surveillance data

Relative Risk for TB – Module 2, p. 10

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Relative Risk for TB (3)Race and Ethnicity, 2014
Race/EthnicityTB Case RateRelative RiskAsians17.829.6Native Hawaiians or Other Pacific Islanders16.928.1Blacks or African Americans5.18.5American Indians or Alaska Natives5.08.3Hispanics or Latinos5.08.3Multiple Race2.84.6Non- Hispanic Whites0.61
Module 2 – Epidemiology of Tuberculosis

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30

Explain that in this table all case rates are compared to the case rate for non-Hispanic whites because non-Hispanic whites have the lowest case rate

Relative Risk for TB – Module 2, p. 10

Race and Ethnicity Study Question 2.6

	Which racial and ethnic groups are disproportionally affected by TB?

	Asians, Native Hawaiians or Other Pacific Islanders, non-Hispanic blacks, Hispanics, and American Indians or Alaska Natives are disproportionately affected by TB. 

Module 2 – Epidemiology of Tuberculosis

31

Introduce study questions 

Ask participants to turn to p. 10 (if participants have print-based modules)

Ask for a volunteer to read question

Ask participants for answers

Answers - Module 2, p. 22

31

People at High Risk for TB Infection and TB Disease

32

Introduce section 

Ask participants who they think should be  considered at high risk for TB infection

People at High Risk for TB Infection and TB Disease - Module 2, pp. 11-15

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High-Risk Groups

High-risk groups can be divided into two categories:

High risk for exposure to or infection with M. tuberculosis

High risk for developing TB disease after infection with M. tuberculosis 

Module 2 – Epidemiology of Tuberculosis

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Review slide content

High-Risk Groups - Module 2, p. 11

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People at High Risk for Exposure to or Infection with M. tuberculosis

Contacts

People who have come to the U.S. within the last 5 years from areas of the world where TB is common

Persons who visit areas with a high prevalence of TB disease

People who live or work in high-risk congregate settings

Health care workers who serve patients at increased risk

Populations defined locally as having an increased incidence of LTBI or TB disease, possibly medically underserved, low-income populations, or persons who abuse drugs or alcohol

Infants, children, and adolescents exposed to adults who are at increased risk for LTBI or TB disease

Module 2 – Epidemiology of Tuberculosis

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Review slide content

People at High Risk for TB Infection - Module 2, p. 11

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People at High Risk for Developing TB Disease after Infection with M. tuberculosis (1)

People living with HIV

Children younger than 5 years of age

People infected with M. tuberculosis within past 2 years

People with a history of untreated or inadequately treated TB disease

People who are receiving immunosuppressive therapy

People with silicosis, diabetes mellitus, chronic renal failure, leukemia, or cancer of the head, neck, or lung

Module 2 – Epidemiology of Tuberculosis

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Explain that anyone who has LTBI can develop TB disease, but that some people are at higher risk than others

Review slide content

People at High Risk for Developing TB Disease – Module 2, p. 11

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Persons who have had a gastrectomy or jejunoileal bypass

Low body weight

Cigarette smokers and persons who abuse drugs or alcohol

Populations defined locally as having an increased risk

Module 2 – Epidemiology of Tuberculosis

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People at High Risk for Developing TB Disease after Infection with M. tuberculosis (2)

Review slide content

People at High Risk for Developing TB Disease – Module 2, p. 11

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High-Risk Groups for TB Infection (1)Contacts

Contacts are persons who have spent time with someone who has infectious TB disease

May include: 

Family members

Coworkers

Friends

Module 2 – Epidemiology of Tuberculosis

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37

Review slide content

Contacts – Module 2, p. 12

High-Risk Groups for TB Infection (2)Foreign-Born Persons/Immigrants

	In the U.S., LTBI and TB disease often occur among people born in areas of the world where TB is common:

Asia

Africa

Russia

Eastern Europe

Latin America

Module 2 – Epidemiology of Tuberculosis

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Review slide content

Explain that the pie chart shows the overall distribution of the countries of birth of foreign-born persons reported with TB in 2014 in the U.S.  The top 7 countries are highlighted.

Ask which of these foreign-born groups live in the participants’ areas

Foreign-Born/Immigrants – Module 2, p. 12

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Mexico(21%)

Philippines(12%)

India(8%)

Vietnam(8%)

China(7%)

Guatemala(3%)

Haiti(3%)

Other Countries38%
Mexico	Philippines	Vietnam	India	China	Guatemala	Haiti	Other Countries	22	11.6	8.4	7.7	5.8	2.5	2.9	38.299999999999997	
Cases of TB in foreign-born and U.S.-born, 

1992 and 2014

High-Risk Groups for TB Infection (3)Foreign-Born Persons/Immigrants

Module 2 – Epidemiology of Tuberculosis

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1992

2014

U.S.-born

73%

Foreign-born

27%

Foreign-born

65%

U.S.-born

35%

U.S.-born

73%

Foreign-born

27%

U.S.-born

34%

Foreign-born

66%

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Explain that the two pie charts show the percentage of TB cases by foreign-born and U.S. born persons in 1992 and 2014

Explain that the percentage of TB cases in the U.S. that are among foreign-born persons has increased over the years (27% in 1992 vs. 66% in 2014)

Foreign-Born/Immigrants – Module 2, p. 12
Sales	1st Qtr	2nd Qtr	27	73	Sales	1st Qtr	2nd Qtr	65	35	
High-Risk Groups for TB Infection (4)Foreign-Born Persons/Immigrants

To address high rates of TB in foreign-born persons, CDC and other public health organizations are working to:

Improve the overseas and domestic screening process for immigrants and refugees

Strengthen the notification system that alerts health departments about the arrival of immigrants and refugees with suspected TB disease

Test recent arrivals from countries where TB is common for TB infection and ensure completion of treatment

Module 2 – Epidemiology of Tuberculosis

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Review slide content 

Foreign-Born Persons/Immigrants – Module 2, p. 12

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High-Risk Groups for TB Infection (5)Foreign-Born Persons/Immigrants

Individuals applying for immigration and refugee status from overseas:

Must be screened for TB by panel physicians before entering the U.S. 

Must have completed treatment before entering the U.S. if diagnosed with TB disease

Module 2 – Epidemiology of Tuberculosis

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41

Review slide content

Explain that health departments are notified of immigrants who are suspected of having TB.  This notification system allows health departments to assist patients to receive a medical evaluation.

Foreign-Born/Immigrants – Module 2, p. 12

High-Risk Groups for TB Infection (6)Foreign-Born Persons/Immigrants

Immigrants living in the U.S. who apply for permanent residence or citizenship:

Must be tested for TB infection and evaluated for TB disease by U.S.- based civil surgeons

Module 2 – Epidemiology of Tuberculosis

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Review slide content

Foreign-Born Persons/Immigrants – Module 2, p. 12

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High-Risk Groups for TB Infection (7)Congregate Settings

In certain congregate settings, the risk of being exposed to TB is higher than other places. This may include:

Correctional facilities

Homeless shelters

Nursing homes

Health care facilities 

Module 2 – Epidemiology of Tuberculosis

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Review slide content 

Congregate Settings – Module 2, p. 13

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High-Risk Groups for TB Infection (8)Congregate Settings

Risk of exposure to TB is higher than in other settings

Risk is higher if facility is crowded

Module 2 – Epidemiology of Tuberculosis

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Review slide content 

Congregate Settings – Module 2, p. 13

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High-Risk Groups for TB Infection (9) Correctional Facilities

Higher risk in correctional facilities may be due to:

Incarcerated population includes a high proportion of people at greater risk for TB than overall population (risk factors may include HIV-infection and a history of homelessness or drug use)

Physical structure of correctional facilities (e.g., close living quarters, overcrowding, potential for inadequate ventilation)

Movement of inmates into and out of facilities can lead to interruption of therapy

Module 2 – Epidemiology of Tuberculosis

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Before showing slide, ask why groups in correctional settings are at higher risk for TB infection 

Review slide content 

Explain that being infected with HIV puts individuals at a higher risk of developing TB disease

Correctional Facilities – Module 2, p. 13

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High-Risk Groups for TB Infection (10) Health Care Workers

Might be exposed to TB at work

Risk depends on:

Number of persons with TB in facility

Job duties

Infection control procedures

Module 2 – Epidemiology of Tuberculosis

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Before showing slide, ask participants which factors can increase the risk for health care workers 

Review slide content

Explain that facilities with a high risk of TB transmission should ensure appropriate TB prevention and control measures are taken 

Note that infection control procedures are discussed more in Module 5

Health Care Workers – Module 2, p. 13

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High-Risk Groups for TB Infection (11) Populations Defined Locally

Populations that may have an increased risk include

Persons experiencing homelssness

Medically underserved populations

Low-income groups

Persons who abuse drugs or alcohol

Module 2 – Epidemiology of Tuberculosis

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Review slide content

Populations Defined Locally – Module 2, p. 14

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High-Risk Groups for TB Infection (12) Populations Defined Locally

Low-income is linked to higher risk of TB exposure

Possible reasons include factors associated with low-income:

Inadequate living conditions

Crowding

Malnutrition

Poor access to health care

TB rates are 10 times higher for people experiencing homelessness

Module 2 – Epidemiology of Tuberculosis

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Review slide content

Populations Defined Locally – Module 2, p. 14

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High-Risk Groups for TB Infection (13)Children and Adolescents

High risk if exposed to adults in high-risk groups

If a child has TB infection or disease, it suggests that:

TB was transmitted relatively recently

Person who transmitted TB to child may still be infectious

Others may have been exposed

Module 2 – Epidemiology of Tuberculosis

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Review slide content

Note that the number of reported TB cases in children have been decreasing since 1993

Children and Adolescents – Module 2, p. 14-15

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High-Risk Groups for TB Disease (1)Infants and Children Younger than 5 Years

High risk for rapidly developing TB disease due to underdeveloped immune system

Module 2 – Epidemiology of Tuberculosis

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50

Review slide content

Infants and Children – Module 2, p. 14-15

High-Risk Groups for TB Disease (2)People Living with HIV

HIV is the strongest known risk factor for developing TB disease

TB is the leading cause of death for people with HIV/AIDS

Risk of developing TB disease is 7% - 10% each year for people who are infected with both TB and HIV (if the HIV is not treated)

Module 2 – Epidemiology of Tuberculosis

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Review slide content

Explain that because HIV weakens the immune system, people with TB infection and HIV infection are at a very high risk of developing TB disease

Explain that the risk of developing TB disease is only 10% over a lifetime for people infected only with M. tuberculosis 

People Living With HIV – Module 2, p. 15

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High-Risk Groups for TB Infection Study Question 2.7

	Name 7 groups of people who are more likely to be exposed or infected with M. tuberculosis.

Contacts of people known or suspected to have TB

People who have come to the U.S. within last 5 years from countries where TB is common

Persons who visit areas with a high prevalence of TB disease

People who live or work in high-risk congregate settings

Health care workers who serve high-risk groups

Populations defined locally as having an increased incidence of LTBI or TB disease, possibly medically underserved, low-income populations, or persons who abuse drugs or alcohol

Infants, children, and adolescents exposed to adults who are at increased risk for LTBI or TB disease

Module 2 – Epidemiology of Tuberculosis

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Introduce study questions

Ask participants to turn to p. 16 (if participants have print-based modules) 

Ask for a volunteer to read question 

Ask participants for answers

Answers - Module 2, p. 23

52

	What are public health agencies doing to address the high rate of TB in foreign born persons? 

Improve the overseas and domestic screening process for immigrants and refugees

Strengthen the notification system that alerts health departments about the arrival of immigrants and refugees with suspected TB disease

Test recent arrivals from countries where TB is common for TB infection and ensure completion of treatment	

Module 2 – Epidemiology of Tuberculosis

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High-Risk Groups for TB Infection Study Question 2.8

Ask for a volunteer to read question 

Ask participants for answers

Answers - Module 2, p. 23

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	Why is the risk of being exposed to TB higher in certain settings, such as nursing homes or correctional facilities? 

Many people in these facilities are at risk for TB disease

Risk of exposure is higher if facility is crowded

Module 2 – Epidemiology of Tuberculosis

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High-Risk Groups for TB Infection Study Question 2.9

Ask for a volunteer to read question 

Ask participants for answers

Answers - Module 2, p. 23

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	What are some reasons why rates of TB disease are higher in correctional facilities? 

The incarcerated population contains a higher proportion of people at greater risk for TB than the general population

An increasing number of inmates are infected with HIV, which means that they are more likely to develop TB disease if they become infected with M. tuberculosis

Some correctional facilities are crowded and may have inadequate ventilation, which promotes the spread of TB

Therapy can be interrupted when inmates are moved into and out of facilities

Module 2 – Epidemiology of Tuberculosis

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High-Risk Groups for TB InfectionStudy Question 2.10

Ask for a volunteer to read question 

Ask participants for answers

Answers - Module 2, p. 24

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	When a child has TB infection or disease, what does it tell us about the spread of TB in the child’s home or community? Name 3 things. 

TB was transmitted relatively recently

The person who transmitted TB to the child may still be infectious

Other adults and children in the home or community have probably been exposed to TB 

Module 2 – Epidemiology of Tuberculosis

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High-Risk Groups for TB InfectionStudy Question 2.11

Ask for a volunteer to read question 

Ask participants for answers

Answers - Module 2, p. 24

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Name 8 groups of people who are more likely to develop TB disease once infected. 

Module 2 – Epidemiology of Tuberculosis

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High-Risk Groups for TB DiseaseStudy Question 2.12

People with silicosis, diabetes mellitus, chronic renal failure, leukemia, or cancer of the head, neck, or lung

Persons who have had a gastrectomy or jejunoileal bypass

Low body weight

Cigarette smokers and person who abuse drugs or alcohol

Populations defined locally as having an increased incidence of disease due to M. tuberculosis

People living with HIV

Children younger than 5 years of age

People infected with M. tuberculosis within the past 2 years

People with a history of untreated or inadequately treated TB disease

People receiving immunosuppressive therapy

57

Ask for a volunteer to read question 

Ask participants for answers

Answers - Module 2, p. 24

	What is the strongest known risk factor for the development of TB disease? 

	HIV infection is the strongest known risk factor for developing TB disease.  HIV infection weakens the body’s immune system, making it more likely for a person who has TB infection to develop TB disease.

Module 2 – Epidemiology of Tuberculosis

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High-Risk Groups for TB DiseaseStudy Question 2.13

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Ask for a volunteer to read question 

Ask participants for answers

Answers - Module 2, p. 25

High-Risk Groups for TB DiseaseStudy Question 2.14

	If a person is infected with both M. tuberculosis and HIV, what are his or her chances of developing TB disease? How does this compare to the risk for people who are infected only with M. tuberculosis? 

Risk is 7% to 10% each year if person is infected with both M. tuberculosis and HIV and the HIV is not treated

Risk is 10% over a lifetime if person is only infected with M. tuberculosis 

Module 2 – Epidemiology of Tuberculosis

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Ask for a volunteer to read question 

Ask participants for answers

Answers - Module 2, p. 25

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Case Studies

60

Introduce case studies

60

Module 2: Case Study 2.1

	For each of the following people, choose the factor(s) known to increase the risk of being exposed to or infected with TB 
PersonFactorsa)  Mr. Petrov___  Works at a nursing home___  Rides the subway every day___  Emigrated from Russiab)  Ms. Montoya___  Was born in Latin America___  Has a father who had pulmonary TB                   disease c)  Ms. Parker___  Volunteers in the emergency room of an                                            inner-city hospital___  Works in a day care center d)  Mr. Dudley___  Was released from prison last year___  Sleeps in a homeless shelter 
Module 2 – Epidemiology of Tuberculosis

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Ask participants to turn to p. 18 (if participants have print-based modules)

Read case study 

Ask participants which factors would be considered risk factors for each person

Answers – Module 2, p. 26

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Module 2: Case Study 2.2

For each of the following people, indicate the factor(s) known to increase the risk of developing TB disease once infected 
PersonFactorsa)  Mr. Sims ___  Injects heroin___  Has HIVb)  Mr. Allen___  Has diabetes___  Has high blood pressure c)  Ms. Li___  Has chest x-ray findings suggestive of    previous TB disease___  Has heart problems d)  Mr. Vinson___  Is overweight___  Became infected with M. tuberculosis 6 months ago 
Module 2 – Epidemiology of Tuberculosis

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Ask participants to turn to p. 20 (if participants have print-based modules)

Read case study 

Ask participants which factors would be considered risk factors for each person

Ask if there are any questions about Module 2  before moving on to Module 3

Answers – Module 2, p. 27

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